Social and Psychological Effects of Overcrowding in Palestinian Refugee Camps
in the West Bank and Gaza - Literature Review and Preliminary Assessment of the Problem

Source: prepared for the INTERNATIONAL DEVELOPMENT RESEARCH CENTRE

by Mona Marshy
August 1999

This work was carried out with the aid of a grant from the Expert and Advisory Services Fund which is administered by the International Development Research Centre, Ottawa, Canada and financially supported by the Canadian International Development Agency in cooperation with the Department of Foreign Affairs and International Trade.

3.1 Parameters of the problem
3.2 Physical conditions of the camps
3.3 The home as a locus of study
3.4 Infrastructure
3.5 Demographics and population densities of camps and households
3.6 Service provision
3.7 Overcrowding and health
3.8 Overcrowding and safety in the home
3.9 Mental health: "Ten people cannot live in one room"
3.10 'Subjective crowding'
3.11 Social conflicts
3.12 Differential impact on various segments of the population

This brief is taken from the summary and recommendations of the Report.

Nature of the problem:

Overcrowding and its associative effects derive from:

the high 'social density' in homes, schools, clinics, camps;

the high 'spatial density' of the camp, in particular, congested buildings and roads, and lack of public spaces, including playgrounds and meeting places;

the burden placed on the already insufficient infrastructure and utilities, including roads, water supply, and electricity, and public services, including health and education.

The social and psychological effects of overcrowding are immediate, long-term, cumulative, multiple, mutually reinforcing, direct as well as indirect, and critical. Overcrowding is likely to worsen.

Where problems of overcrowding manifest:

Overcrowding affects all segments of the refugee camps' population in common and particular ways. Social and psychological effects of overcrowding are experienced among individuals and within relationships at the following levels:

within households, due to:

lack of personal privacy

exposure to others' behaviours and personal activities between families and households, since:

multi-family households are common and space within households is constricted within the camp as a whole, due to:

physical congestion

crowded and overburdened social services, and

limited public spaces and buildings for meeting socially

between camp residents and the wider society in the West Bank and Gaza, due to:

marginalization of refugees as a group within wider society

The social and psychological effects of overcrowding:

The social and psychological effects of overcrowding can be summarized as follows:

Health effects:

Overcrowding poses serious direct and indirect health risks to all segments of the population, particularly the elderly, young children, and the disabled:

lack of space and overcrowding directly impacts on the physicial development and psychological well being of disabled residents.

Social effects:

Overcrowding contributes to far-reaching social problems:

it places a strain on social relations within the home and community;

overcrowding in schools and homes is linked to substandard education and functional illiteracy, and may be related to increased child labour;

it is a 'push factor' in the decisions leading to girls' early marriage (before the age of 18) which, in turn, leads to serious health and social ramifications for women and children;

overcrowding affects women's access to social and economic resources; it increases their responsibilities in the home and burdens their time.

Psychological effects:

Direct and indirect psychological effects result from overcrowding:

lack of privacy is linked to depression and other negative psychological outcomes;

overcrowding contributes to psychological frustrations which, in turn, have a bearing on behavioural responses and residents' ability to cope with the conditions;

refugees' perception of options and future prospects is detrimentally affected by overccrowding.

Local and international NGO response to effects of overcrowding:

There are few programmes on the part of NGOs, and insufficient resources allocated, to address social and psychological effects of overcrowding. Nonetheless, there is a great deal of concern by stakeholders about the issue and a belief that it is of critical importance.

Recommendations for further study of social and psychological effects of overcrowding:

There is not enough information or analysis on the direct and indirect effects of overcrowding. There is a need for further study to unravel the inter-relationships of numerous effects and conditions associated with overcrowding.

Further study should:

involve direct 'on the ground' information gathering from those working and living in refugee camps;

include both qualitative and quantitative data gathering including:

- qualitative one-on-one interviews and focus group discussions with segments of the population (youth, elderly, disabled, women, girls, boys, men) and service providers;

- quantitative survey research on a representative sample of camp households and service providing agencies;

aim to the develop programmes or projects that can address short-, medium- and long-term needs and issues.

Finally, despite lack of agreement on the part of stakeholders concerning substantive issues linked to any solution to overcrowding, there is an urgency around the issue as well as sufficient scope to address the issues above.

1. Introduction

1.1 Objective

The objective of the paper is to examine the social and psychological effects of overcrowding in Palestinian refugee camps in the West Bank and Gaza.

1.2 Structure of paper

The inquiry proceeds in three main segments. Section 2 summarizes the theoretical and empirical literature on overcrowding in developing and developed countries. The limited number of studies on social pressures from overcrowding in Palestinian refugee camps are looked at. The literature on health effects of overcrowding is treated separately, as are empirical measures used by researchers to gauge the extent of overcrowding.

Section 3 focuses on the specific social and psychological effects of overcrowding in refugee camps in the West Bank and Gaza by drawing both on available empirical studies relating to the issues as well as on data obtained through interviews with officials of non-governmental organizations and UNRWA representatives responsible for provision of social services in the camps. In Section 4, information and profiles are provided on non-governmental organizations in two segments that list: NGOs with programmes addressing problems resulting from overcrowding in the camps; and, NGOs with programmes directed at other segments of the population but which may be extended to address the needs of refugee camp residents. The conclusion provides a recap of the findings as well as recommendations.

1.3 A note on the research process

It should be emphasized that the findings and conclusions made in this paper remain preliminary. Some constraints were encountered during the collection of interview data via telephone, including difficulties reaching people by telephone due to the time differences, and by email due to both technical problems in the West Bank and Gaza with email transmission. Furthermore, numerous people were on vacation and thus unavailable during the time that the interviews were conducted. Perhaps most importantly, many individuals who were contacted were reluctant to give information over the telephone, especially on the issues relating to the social psychological effects of overcrowding. Those who were most able to provide first-hand information on the health and psychological pressures faced by refugees in the camps (physicians working in UNRWA clinics) were also the more difficult to reach by telephone, and the most pressed for time when they were contacted; they were also the least likely to have access to email facilities, and the most constrained in terms of the information they felt they were able to provide in their capacity as medical professionals. Also, the limited time and scope of the study did not allow for verification or cross referencing of the information obtained in interviews. Despite these limitations, a good deal of information was collected, mostly on specific conditions in particular refugee camps, as well as general information on the overall situation and effects of overcrowding. Finally, intense interest in the issues of overcrowding, and the present research in particular, was expressed by both UNRWA and NGO representatives I spoke with.

There is a substantial body of literature on the social and psychological effects of overcrowding, though its focus is primarily on urban environments and households in industrialized countries. Theoretical as well as empirical studies of overcrowding in the context of the Middle East in general, and the West Bank and Gaza Strip in particular, are sparse. Similarly, the impact of household or urban overcrowding on the social and psychological well-being of citizens of Third World cities and refugee camps remains largely unknown. Furthermore, studies which look at the social and psychological concerns of refugees focus on their adaptation processes in 'host' countries. And empirical studies on refugee camp conditions tend to be oriented toward pragmatic concerns of aid and service delivery, rather than on social pressures resulting from overcrowding.

Despite these gaps and shortcomings, there are important theoretical concepts and findings on social and psychological effects of overcrowding which are useful to an examination of the issue in the context of the West Bank and Gaza. In particular, studies conducted on household overcrowding in Bangkok (Fuller et al. 1993; 1996), India (Ruback and Pandey 1991), Jakarta and Bissau (Guinea Bissau) (UNCHS 1995), as well as Chicago (Gove and Hughes 1983) provide important insights.

The review of literature focuses on theoretical concepts and notes some conclusions of researchers regarding social and psychological effects of overcrowding within households and urban communities. Particular attention is given to dimensions most often addressed in the literature: social behaviour and relationships, psychological well-being, and physical health. Also outlined in this section are the indicators employed by researchers to measure overcrowding, as well as selected findings from surveys of household and refugee camp conditions in the West Bank and Gaza.

2.1 Important theoretical concepts on overcrowding

Social and psychological effects of overcrowding are looked at in the literature from various disciplines, including sociology, psychology, urban geography, behavioural sciences, and epidemiology. A number of classic studies focus on the effects of overcrowding in both human and animal populations. The classic work by Simmel, The Metropolis and Mental Life (1903), looked at the coping mechanisms of the individual in the context of urban crowding. These coping mechanisms, including retreating into personal space for psychological and emotional renewal, were jeopardized by the multitude and variety of social interactions, resulting in sensory overload on the part of the individual within the increasing population density of city centres. Such early theoretical formulations influenced later studies that maintained a focus on the individual in society.

Overcrowding and crowding are used interchangeably in the literature. (This study tends to use the former term, though no distinction is intended.) Overcrowding is usually defined as the presence of too many people in the available space and facilities. The concept and measurement of overcrowding vary greatly between continents, countries, regions, and communities, and depend on cultural, social, economic, seasonal, geographical, and political factors (Clauson-Kaas 1996:351). Studies of overcrowding are usually conducted at two main levels: the household level, measured in persons per area of living space; and area level, measured in people per area of land. Other levels of crowding that are also pertinent, especially in studies of health effects of crowding, are room-level (including 'bed crowding') and building-level crowding.

Gove and Hughes (1983) distinguish between objective crowding and subjective crowding (1983:74). Objective crowding is measured quantitatively at the household level by number of persons per room. Subjective crowding, on the other hand, refers to one's perception of not having enough space in the home (Gove and Hughes 1983:xvii).

The literature distinguishes further between social density (the number of people interacting in the household) and spatial density (the floor space per person) (Ruback and Pandley 1991).

These concepts are all pertinent to the context of Palestinian refugee camps in the West Bank and Gaza. The notion of subjective crowding comes into play as refugees' link the conditions of overcrowding in the camps to their long-standing frustrations with the wider political issue. The sense that their plight has for so long been ignored and remains unresolved increases their frustrations with conditions in the camps and affects how they experience the objective conditions of overcrowding.

2.2 Selected findings in the literature on overcrowding

In what is widely recognised as a seminal study of overcrowing in households, entitled Overcrowding in the Household: An Analysis of Determinants and Effects, Gove and Hughes (1983) conclude that the number of rooms available per person plays a critical role in determining the nature of interactions in the household, and is related to poor mental and physical health. They found also that objective crowding affects negatively parents' relationships and interactions with their young children, sexual behaviour between couples, and social relationships with those living outside the home. A central aspect of subjective overcrowding is a "felt lack of privacy," including a feeling of lack of control over others' access to information about oneself and one's life.

Gove and Hughes' (1983) investigation also produced evidence that the relationship of subjective experience of crowding to mental health is stronger than the relationship between persons per room (objective crowding) and mental health (Gove and Hughes 1983:75). Gove and Hughes underscore the fact that perceptions of overcrowding are an important aspect of the lived reality, and should be considered as such. In other words, perceptions (subjective crowding) toward their environment need to be considered as of parallel importance as the quantifiably measured conditions of overcrowding (objective crowding). This finding is useful for informing researchers and stakeholders concerned about the issue of overcrowding in refugee camps in the West Bank and Gaza.

Gove and Hughes assert that the subjective experience of overcrowding is determined by too many social demands and a lack of privacy, and that the experience of these interferes with one's behaviour and mental health. They also find that crowding has a greater effect on mental health for women (Gove and Hughes 1983:16).

Fuller's study of psychological well-being and household overcrowding in Thailand considers crowding as a chronic stress which is accompanied by lack of privacy. He found that wives who feel they lack privacy are more likely to contemplate suicide (Fuller et al. 1996:276). Fuller's studies on overcrowding are unique in their attempts to unravel the complex interaction between individual behaviours, the physical environment, and cultural norms and expectations which mitigate the effects (Fuller et al. 1993, 1996).

Baum and Koman's study of the psychological effects of social and spatial density found that people living in high social density environments were more likely to become socially withdrawn, while responses to spatial density would be include aggressive behaviour (Baum and Koman 1976). Other findings in the literature include the 'selective and modest' effects of overcrowding on human sexual behaviour (Edwards and Booth 1977). Crowding in the household is also seen to exacerbate the effects of high density in the surrounding area. High population density in urban areas, in particular, "the disintegration of small community associations that give individuals health social contacts, security, social control, personal identification and stability of culture" is linked to increased levels of emotional stress, social disorganization, and physical conflict (Morgan 1972). It has been also found that anxiety and hostility tend to intensify over time in situations of overcrowding (Zeedyk, et al. 1983).

Although the effects of overcrowding per se have not been thoroughly studied in the West Bank and Gaza, there is data on housing conditions in Palestinian refugee camps in and around Amman, Jordan, which has been collected (Abu Helwa and Birgh 1993). And there is an important source of data on housing conditions among refugee camp, village, and city residents of the West Bank and Gaza that is available (Heiberg 1993).

These surveys provide important baseline information about density. For example, in the camps in Amman, there was an average of 3.9 persons per room among the sampled households, with half living at a density of 4 or more persons per room and about 5 percent living at 8 or more persons per room. Moreover, the survey found that noise outside the home was equally a cause for dissatisfaction as was lack of space within it. It also found that households which had lived in the area longer were less satisfied with their living conditions than shorter-term residence, reflecting perhaps a build-up of frustration over many years. Observations on the social effects of overcrowding are indirect. For example, the authors note that the school dropout rate among refugee children in the camps in Jordan lags well behind that for the population of Jordan as a whole. It is not clear whether a correlation can be made between this fact and the condition of overcrowding (Abu Helwa and Birch 1993:407, 409-11).

The survey of housing conditions in the occupied territories, conducted by Marianne Heiberg as part of a comprehensive survey of living conditions undertaken by FAFO also makes observations on satisfaction levels of residents. The report confirms the significance of extraneous factors in an individual's satisfaction with their home environment. Heiberg notes, for example, that the experience of overcrowding within homes is dramatically affected by human density in adjoining space. She states:

It makes a great deal of difference to a person's sense of overcrowdedness if an overcrowded household is surrounded by large, tranquil areas of agricultural land or is tightly and noisily entrapped between other overcrowded households (Heiberg 1993:86-87).

From the FAFO survey we know conclusively that refugee camps in Gaza have the highest density (in the West Bank and Gaza) in terms of persons per room, and that overcrowding of Gaza households is exacerbated by the high congestion in Gaza generally (Heiberg 1993:86). Other data, including municipal services, which impact on the general welfare of residents, was not collected; nor was the survey aimed at assessing social and psychological effects of housing conditions and overcrowding.

Given that there are no studies examining mental health effects of overcrowding in Palestinian camps, one can try to glean from related literature and studies. A study of the psychological effects of the Intifada on Palestinian children in West Bank refugee camps, villages, and cities (Baker 1991) is interesting and useful on two counts. Its findings are disaggregated and enable an analysis of the particular psychological effects experienced by children in the camps; and the study suggests the importance of looking at the ongoing mental health effects of the stresses experienced during the Intifada. Baker found that conduct problems (in particular, fighting with others, jealousy, irresponsibility) were more severe among children in refugee camps, as compared to those in villages and cities (Baker 1991:241). The most pressing psychopathology problem during the Intifada was fear of leaving the home (Baker 1991:243).

Whether and how these psychological problems might manifest in the present period and in the future would require further study. The study's conclusions do indicate the importance of examining the relationship of different stress to psychological pressures caused by overcrowding.

A study by Samir Qouta, et al., on the mental health effects of house demolition in Gaza concludes that in traumatic conditions women's mental health is especially vulnerable. The nature of the traumatic experience determines the extent and nature of psychological problems (Qouta, et al. 1997:209). Overcrowding, generally, is considered a chronic stress which exacerbates other stresses.

The health effects of overcrowding are more quantifiable than are psychological effects. The following sections examines findings in the literature on the relationship between overcrowding and health.

2.3 Overcrowding and health

Until the last two decades, it has been assumed that people living in crowded conditions have ill health because they are poor. European data from the turn of the century considers 'overcrowding' as being synonymous with poor housing conditions. Importantly, writers made no attempt to ask why overcrowding as such would lead to poor health. 'Overcrowding,' 'unhygienic' and 'unsanitary' conditions were assumed to explain the poor health conditions and high mortality rates among the working classes (Halliday 1928; Wright 1942; ref: UNCHS 1995).

This concern about the link between housing conditions and health disappeared with medical advancements in the 1940s (UNCHS 1995:6). More recently, concern about the health impact of overcrowding is emerging in both developed and developing countries in conjunction with malnutrition and lack of sanitary hygiene. One of the first attempts to quantitatively ascertain the relationship between in-house crowding and health was undertaken by the United Nations Centre for Human Settlements (Habitat) in 1992. In the course of a two-year study of two urban communities in Bissau, Guinea Bissau and Jakarta, Indonesia, overcrowding was measured at the level of room, household, building, and area.

The study affirms that the transmission of disease increases among people living closely together (UNCHS 1995:6). Specifically, overcrowding increases the risk of infection as the number of potential transmitters is increased. The result is that children and adults living in crowded conditions get more infections and more severe infections.

Young children carry the largest burden of morbidity and mortality. Hence, many small children in a household increase the risk of acquiring a communicable disease for all household members. In the case of a number of highly communicable diseases, young children are more potent transmitters than older children and adults (UNCHS 1995:45). The UNCHS study investigates crowding as a risk factor for low birth weight, diarrhoeal morbidity and childhood mortality. The study suggests that rather than the traditional measure of persons per room, a better indicator is 'bed crowding' and 'crowding of small children' as these seem to give a more sensitive indication of crowding as a risk to increased mortality (UNCHS 1995:16).

The higher risks of infection leads to infection at a younger age which, in turn, is a determinant of severity and fatality of the disease. The higher number of susceptible individuals per family is a risk factor for mortality. Overcrowding is also considered to increase the risk of, in particular, the long-term adverse effects of infections (UNCHS 1995:7-8).

Several studies suggest that illnesses such as whooping cough, polio, diarrhoea, malaria, meningitis, acute lower respiratory infections (ALRI), influenza, hepatitis A, hepatitis B, helminth diseases, stunting, chronic diseases, and stress may be related to crowding (Bradley, et al. 1992:6). There is clearly a recognition of the need to improve human settlements with the purpose of improving health. The UNCHS (1995) underlines the importance of the provision of water supply and sanitation for households, with expected benefits being a decrease in diarrhoeal, intestinal, and respiratory diseases (in developing countries the respiratory diseases are the dominating cause of disease burden for children under 5, a leading cause for the age group 5 to 14, and the dominating communicable disease for adults and the elderly) (UNCHS 1995:55).

Child health and safety issues are touched on briefly in analysis of survey data on housing in the West Bank and Gaza (Heiberg 1993:94-5). One of the more interesting pieces of data collected in FAFO's survey of housing notes that West Bank refugee camp residents find their houses two times safer than Gaza camp residents, implying, according to Heiberg, a relationship between the human density of the house and perceptions of the safety that the house affords young children.

Because people's behaviour and cultural practices mitigate environmental effects of crowding, it is important to examine area crowding in terms of how individuals interact with the surrounding physical and social conditions. The 1993 World Health Organization document on guidelines for developing strategies related to health, environment and development provides what is considered a broad, socio-political and progressive definition of the environment. It states:

in relation to human health¼ the 'environment' includes not only the physical and biological elements of nature, but also human-based systems-cultural, artifactual, economic, political, technological, spiritual and relational-that make up the settings in which people live (Shaefer 1993).

Attempts to account for the complexity of 'human systems' is operationalized by researchers through a series of empirical indicators used to measure overcrowding. The following section outlines these.

2.4 Empirical measures of overcrowding

The most commonly used indicators for in-house crowding are person/room and room area/person. Housing is defined as a house, shelter or dwelling. A household is one or more families or individuals "who make common provision for food or other essentials of living" (Clauson-Kaas, et al. 1996:352). Household overcrowding in western societies is calculated in terms of the proportion (or number) of homes with more than one person per room. The Housing Strategy for Jordan considers a ratio of 2.5 persons per room a yardstick of household overcrowding (Abu Helwa and Birch 1993:409). UNDP defines habitable rooms as: "¼ a space in a housing unit, or other living quarters enclosed by walls reaching from the floor to the ceiling or roof covering, at least to a height of two metres, of a size large enough to hold a bed for an adult" (UNCHS 1995:101).

In the West Bank and Gaza, persons per habitable room can sometimes be a misleading indicator as, in Palestinian homes, a disproportionate amount of space is often occupied by the living room or salon (Heiberg 1993:84). Nonetheless, we do know from survey data that in refugee camps in Gaza, more than 40 percent of households have a density of three persons or more per room. In Gaza Strip towns and villages, about 38 percent of households comprise three persons or more per room. Gaza City and West Bank refugee camps both have about 28 percent of households with three persons or more per room.

Other room level indicators include:

Number of persons/bedroom

Bedroom area/person

Number of persons/bed

Number of children under 5/room

Total room area/children under 5

Number of children under 5/bedroom

Bedroom area/children under 5

Number of children under 5/bed

Household level indicators used in most studies would include two or more of the following:

Number of rooms/household

Number of households/house

Number of persons/house (adults, children)

Number of persons/household

Room area/person

Others/room (this is measured over a specific time, to take into account that not all household members are at home all the time)

While most dwellings in refugee camps comprise either a nuclear or extended family, building level indicators are useful when the extended family comprises several nuclear families in adjoining buildings. These would include:

Number of households/building

Number of housing units/building

Number of households/housing unit

Number of persons/housing unit

Number of persons/building

Area level measures are used to measure density or crowding in the community as a whole. The calculation of people per area is measured in terms of gross-area or net area. Gross-area refers to persons per area of land. The calculation of net-area accounts for parks, industry, institutions, as well as pressure on public facilities (Clauson-Kaas, et al. 1996:354). The following measures are used:

This section begins with an outline of the physical conditions of the refugee camps in the West Bank and Gaza, including Shufat Camp, located within the municipal borders of Jerusalem. The provision of social services is reviewed. The discussion of the effects of overcrowding focuses on the particular pressures faced by women, children and youth, men, the elderly, and disabled refugees.

This portion of the paper draws on telephone interviews conducted in June and July, 1999, with representatives of UNRWA and local and international NGOs. UNRWA personnel in several camps and NGO representatives provided general as well as specific information on issues and programmes relating to overcrowding. Recent documents on camp conditions and housing obtained from local NGOs are also drawn on. There was complete agreement among those who gave interviews, that the problem of overcrowding is a serious one, with many social and psychological ramifications for every segment of the population in the camps.

3.1 Parameters of the problem

The fact that camps have not expanded beyond their original boundaries and the increasing population density are the two main causes of overcrowding in the camps.

Overcrowding is more acute in camps located near municipal boundaries where rental costs are exorbitant. Human crowdedness or density in the West Bank and Gaza is most acute in the Gaza refugee camps (Heiberg 1993:86). Overcrowding in households in Gaza refugee camps is exacerbated by the fact that the shelters are made with substandard building materials such as zinc and asbestos roofs (Heiberg 1993:96).

3.2 Physical conditions of the camps

All Palestinian refugee camps started with tents erected in a grid system. In the mid-50s, UNRWA began to encourage refugees to build their own shelters in the camps to replace the tents. Bricks and asbestos were provided for camp residents to build units of uniform specified dimension:

'AA units' were 6 x 3 metres, comprising of two rooms connected with an inside corridor, and housed 11-12 member families; finally,

'BB units' measured 8 x 4 metres, which housed families of more than 12 members in two rooms.

At this time, UNRWA schools, clinics, distribution centres and offices, as well as public latrines (which no longer exist as all homes have indoor toilet facilities) were constructed.

By the end of the 1950s and early 1960s, refugees began constructing additional rooms next to their units, as well as indoor toilets. The old prefab units were substituted by block rooms, with a small courtyard to grow a vine or lemon tree or vegetables. Some refugees gave up some of their plot and converted it into shops which lined the main streets (Budeiri 1996). As families grew, still more space was needed and the ground floor was expanded, eliminating the courtyard.

By the beginning of the 1980s, the housing units had became stabilized in terms of space but the population continued to increase, precipitating a housing crisis (Mansour 1998:3). Refugees at this time began to rehabilitate their shelters and construct new, more spacious ones with cement and iron bars (though some poorer refugees still live in the dwellings built in the mid-50s). UNRWA provided building permits but did not supervise the construction itself. In the camps situated adjacent to towns, construction of homes was not able to spill over the boundaries of the refugee camps; hence, these camps' residents were the first to add a second story onto their shelters (Mansour 1998:3). UNRWA approves the two-story constructions but will not authorize construction of third and fourth stories.

The absence of laws during the Intifada encouraged the process of encroachment on public yards and by-roads. Public squares disappeared, the main asphalt public roads became very constricted, and the smaller roads became extremely narrow. Gardens and trees, planted in initial attempts to mimic the environment of refugees' original homes, were replaced by room additions or extensions (Mansour 1998:4). Families considered by UNRWA as 'special hardship cases' qualify for new shelters from UNRWA if their own has been demolished or become dilapidated. The Agency provides one 3 x 3 metre room, and a kitchen and bathroom for the family, as well as cement and cash assistance. While these shelters are better constructions than those built in the 1950s, they do not satisfy the housing needs of the families. An extreme example of their inadequacy is witnessed in Aqbat Jaber camp near Jericho where 40-50 shelters (of 3 x 3 metres at a height of 2.5 metres) were constructed and are all now being used for storage rather than living quarters. The very high temperatures in the Jericho area are such that ceiling fans are a necessity and the constructed shelters were not high enough to enable a fan to be installed on ceilings (Mansour 1998:4). It should be noted, however, that the Jericho area camps do not suffer from a housing crisis.

Before the Intifada, some refugees built in the areas surrounding camps. With the surge in prices of land since the start of the peace process, people are unable to afford to buy any land. The crisis surged to the point where, for example, in Jenin camp "there are typically 10 children living in each two room house." In some camps, such as Dheisheh camp near Bethlehem, there are many houses whose construction was started but not completed as the family ran out of money. Other families have sometimes occupied these half-built structures, living within the walls, with no roof, windows or flooring.

3.3 The home as a locus of study

The Palestinian refugee home has played important social, political and historical roles. The physical organization of the home and refugee camp has been a factor in maintaining social cohesion and political aspirations of refugee communities. The layout of the camps and design of homes in the years following 1948, and, more recently, the physical presence of the houses and camp boundaries express the political aspirations of Palestinian refugees. The experience of the Intifada has also shaped the role of the home and environment for Palestinian refugees in particular ways.

Cultural norms play a large role in how spaces and environments are experienced. It is sometimes believed that household crowding is mitigated by cultural norms and expectations. It is important to recognize, though, that cultural norms are dynamic and do not always function as buffers against the negative effects of overcrowding. For example, it is historically customary for Palestinian sons to live with their wives in the same or adjoining household as their parents. This custom developed in the context of an agricultural setting, where the household was able to physically and economically expand along with the growth of the family. Also, historically, the cultural background, education level, and thinking of the daughter-in-law, the newcomer to the household, would not have been very different from that of her husband and his parents. Today, there is less social homogeneity. As one UNRWA representative explained:

Within the family, the wife may not have the same thinking, culture, education as her husband's mother. Parents of the wife will try to ask for separate housing as part of the marriage agreement. This sometimes creates conflicts between the parents of the wife and the son-in-law and/or his parents.

3.4 Infrastructure

Land for the provision of school extensions, health centres and other installations is becoming scarce within the camp boundaries. UNRWA schools are invariably overcrowded, with 45 to over 60 students in each classroom, and students attending in double shifts through the day. Teaching quality is reported poor, with new, unqualified teachers hired on contract (as UNRWA cannot afford to hire them permanently). Many of the schools also need to be replaced.

Medical services are also overburdened. Each camp has at least one health clinic.

Doctors working in clinics in the camps typically see over 100 patients per day. The healthcare services provided by UNRWA are distributed on the basis of one health clinic per 10,000 persons. This, however, is insufficient to address current needs, given the high average patient load per doctor (Giacaman 1994:52). Rita Giacaman, who has conducted extensive research on health care, suggests that a ratio of one comprehensive primary healthcare centre is needed for each 5,000 people (Giacaman 1994:52). Camp residents are sometimes obliged to seek health services outside of the camp which places greater financial burdens on them.

3.5 Demographics and population densities of camps and households

Overcrowding in the camps is expected to continue to increase. Nearly half the refugee population is under 14 years of age (Budeiri 1996:73); and the Palestinian population in the West Bank and Gaza has one of the highest fertility rates in the world, at 5 percent per year (Bellisari 1994:54).

The average area density of the refugee population living in camps in the West Bank and Gaza as a whole, is estimated at 37.35 sq metres per individual (Mansour 1998:6, 8). The camps, though, are not uniformly overcrowded. Most of the urban camps may be characterized as 'urban slum areas' because of their physical and socio-economic similarity to slum areas in other developing countries. On the other hand, some camps are situated in rural areas which provide agricultural work for refugees (Abu Libdeh et al. 1993:41).

In Camp No. 1, located within the municipal boundaries of Nablus, there are 1,160 families living in a 44 dunum area. There are no longer any single story shelters in the camp, with 60 percent of the buildings three stories high, 30 percent two stories, and 10 percent four stories. The individual share of this area is 7.8 sq metres.

Shufat camp, established in 1966, has about 20,000 residents, more than half being, in fact, non-refugees who, not being able to afford to build in other areas of Jerusalem, resorted to living in the camp in order to maintain their Jerusalem residency status. Shufat camp is particularly overcrowded because any housing built on land adjacent to the camp has been demolished by the Israeli authorities (Mansour 1998:6).

3.6 Service provision

The case of Dheisheh Camp: In Dheisheh Camp, located near Bethlehem, there is a population of 11,000 living in 1 sq km. The UNRWA Director of the Camp, Hussein Shahin, summarized the overcrowded state of the camp, in noting "each family tries to make use of every single centimetre in the camp." In summer, there is a water shortage, in winter, an electricity shortage. Hussein Shahin noted that the water pressure is not sufficient to reach the higher parts of the camp for ten days per month. There are no wells and not enough water tanks. No more water tanks will fit on top of families' homes as the roofs are in danger of falling through. The electricity lines were installed in 1973 and are now no longer enough, with washing machines, fridges, electrical equipment.

Sewage removal in Jabalya and Shati (Beach) Camps in the Gaza Strip: Only 20 percent of all camp dwellings in the Gaza Strip are connected to sewers (Hoadley and Cook 1992). Camps generally have a system of exposed drains. In Jabalya and Shati Camps, small open channels conduct household wastewater into larger channels which are choked with trash. During fishing season, when the openings to the sea are sealed, and during the winter when it rains, the camps are flooded with waste and sewage (Bellasari 1994:57). This poses a serious health risk that is exacerbated by overcrowding.

The constricted space between homes makes it difficult and sometimes impossible for garbage removal vehicles to operate. Large piles of garbage accumulate, representing a health hazard and a source of considerable frustration.

The burden on households: The lack of sewage systems in many camps has led to refugee households obtaining their own septic tanks. In Fara camp, north of Nablus, there are more than 1000 septic tanks. Leakage from these tanks is a risk to drinking water as well as to the foundations of the shelters (Mansour 1998:7). The waste also leaks down into the water table, the source of drinking water. In consequence, drinking water that is consumed often causes serious gastro-intestinal disease, which is especially dangerous to the health of children and the elderly. Water-borne and respiratory diseases are common among Palestinian camp refugees in the region, and infant mortality is still unacceptably high despite a reduction in the rate (Budeiri 1996:73).

3.7 Overcrowding and health

According to international experts:

The basic essentials for public health are proper housing, adequate nutrition, and a clean, sufficient water supply. Because these factors are the primary determinants of a population's health status, they have priority over all others, including adequate medical care (Bellisari 1994:52).

The availability of sufficient potable water is a problem in the West Bank and Gaza generally. Some areas are worse than others. For example, the Hebron area has lacked water for the past two months of this year (June and July, 1999) and the shortage is expected to worsen. In Gaza, salination is a serious problem and believed to be responsible for liver and kidney disfunction and failure (Bellisari 1994:55). Infectious illnesses are also caused by poor and insufficient water supply.

Anna Bellisari, a health researcher who writes about the health risks of water shortage in the West Bank and Gaza, explains that:

Water shortages and pollution, especially in vastly overcrowded camps, are classic preconditions for infections such as viral, bacterial, fungal, and parasitic diseases, either waterborne or associated with poor public sanitation and personal hygiene (Bellisari 1994:59).

Birzeit Community Health Unit reports that 48 percent of elementary schoolchildren in three West Bank camps were infected with intestinal parasites; malnutrition accompanied the parasitic infections, making the children more susceptible to infection (Bellisari 1994:59-60). The potential for epidemics is very high, and severe and long-term consequences are anticipated unless the water crisis is alleviated (Bellisari 1994:61). As noted in Section 2, these health risks are greatly exacerbated by overcrowding in the home and camp.

3.8 Overcrowding and safety in the home

Overcrowding in West Bank and Gaza camps affects safety within the home in several important ways:

The safety of the physical structure of the dwelling is jeopardized by the need to build vertically, given the lack of space to extend homes by side additions.

Toilet facilities are burdened by the number of people using them which can lead to health risks.

The high number of people in the household puts a burden on water resources in the home and leads to insufficient water for consumption and hygiene-which poses a health risk.

The safety of Kitchen facilities decreases when they are used in overcrowded homes.

The constricted space in and around the home means that the safe storage of agricultural and other chemicals is more difficult to ensure.

Accidents in the home are more likely to occur as sufficient supervision of young children is often difficult.

To elaborate on the first point, the physical structures of the homes, with additions built hastily with no adherence to building safety codes, pose a safety risk. Second and third floors, and sometimes fourth floors, are built on the initial single story dwelling and rest on a foundation that wasn't meant to support the additional levels. UNRWA provides permission to build a second story but there are no building standards. People often build without the required permits, especially if constructing third or fourth stories as they do UNRWA does not issue permits to build beyond the second story. An UNRWA representative relayed that it is not easy to control the quality of construction in the camps as there are limited staff and no site engineers or funds to provide these essential services. To provide sufficient supervision to ensure building standards, a total of 100 engineers would be required in the West Bank alone, amounting to four to five engineers per camp.

In terms of accidents in the home, David Satterthwaite, Director of the Human Settlements Programme at the International Institute for Environment and Development (London), notes that accidents in the home greatly increase in overcrowded conditions:

Many accidental injuries arise from poor quality, overcrowded housing-not surprisingly considering that there are often four or more persons in each small room in shelters made of flammable materials and that there is little chance of providing occupants (especially children) with protection from open fires or stoves (Satterthwaite 1995:viii).

Pesticides are often stored in homes where, because of lack of space, children have ready access to them. Because Palestinian farmers often cannot read the Hebrew instructions on toxic chemical fertilizers, they often mix, apply, and store them without taking any safety precautions. (Bellisari 1994:57).

3.9 Mental health: "Ten people cannot live in one room"

This was often the first response of those I interviewed by telephone regarding mental health effects of overcrowding. It is a simple logic that is deeply understood. Exploring the very intertwined effects of 'ten people living in one room' proves more complicated.

Khaled Mansour, a researcher who has examined the problem of housing in refugee camps in the West Bank and Gaza, notes that living in refugee camps has created "special features of behaviour for the refugees who find it difficult to assimilate into the non-refugee communities" (Mansour 1998:6). Aggressive behaviour of the refugees was also noted by some of those I spoke with during the course of this research. An UNRWA represented commented that:

Psychological effects are noticable. Tempers of refugees are hotter than others, by mere observation. When they ask for something, they do not ask with good tempers, they shout and scream and are nervous.

Attaining psychological help and counseling is hampered by taboos. Qouta notes that former political prisoners refuse these services because "they have been welcomed back as heroes, and psychologically you can't be both a hero and a 'mental case' at the same time" (Doughty 1996:85). Overcrowding might also contribute to the generalized frustration of residents with their plight; spatial constraints reinforce the constriction of the future. As a woman in Khan Younis refugee camp reported to Doughty: "our mythology, our dreams, all look north and south, not here to the Strip. North we look to the land we lost, and south we look to Egypt, which we are told in schoolbooks is a kind of paradise. So two paradises we cannot have, while we live here in hell" (Doughty 1996:74).

3.10 'Subjective crowding'

As noted in the review of literature in Section 2, subjective crowding, or the felt experience of crowding, is as important as objective conditions. For residents of refugee camps in the West Bank and Gaza the fact that they represented the stronghold of the Intifada, suffered considerable personal loss, and have had their expectations rise with the establishment of the Palestinian National Authority, there is a feeling among them that their housing problems should be a priority (Mansour 1998:8). This expectation would play a role in how they experience overcrowding and their behavioural responses to it.

3.11 Social conflicts

The social level: Conflicts arise often in the camps due to irritations from noise, lack of privacy, the proximity of neighbours, and lack of playgrounds or parks. There are very few play areas for children in the camps. Hence, conflicts between kids often create conflicts between their parents. It is felt that these problems would not exist if there were no overcrowding. Solutions are found which provide for ways of recreating social cohesion. For example, Arroub Camp, south of Bethlehem, has a committee of 17 'old people' which solves problems and conflicts between people.

But, overcrowding in the camps also affects more profound social processes. In Camp No. 1, the deceased must be moved from one shelter to another through windows so as to reach the main street to be placed in the coffin (Mansour 1998:6). In Rafah Camp in Gaza, where lane-ways do exist, there is not enough room for both a coffin and people on each side to carry it, hence the deceased are carried in coffins over roofs.

The individual level: Overcrowding affects social relations at the family, neighbourhood, camp, and community level in extremely complex ways. At the individual level, frustration is experienced because, typically, the refugee camp resident:

is living in overcrowded housing and in an overcrowded camp;

cannot afford to move outside the camp;

cannot afford to build an extra floor;

cannot afford, or is unable because of lack of space, to build an extension to the dwelling structure;

does not have sufficient employment which would enable them to opt for any of the above in the near future;

is a member of a growing family with increasing expenses and decreasing resources and space for housing;

is faced with a situation whereby the conditions which would enable him/her to change their situation are themselves jeopardized by the effects of overcrowding (which include increased frustration level; decreased ability to concentrate on schooling or training; increasing expenses because of greater health risks).

In the course of extensive research undertaken in camps in the West Bank, Dr. Najih Jarrar, at al-Najah University in Nablus, witnesses the day-to-day frustrations of refugees. He reports on what he describes as the common experience:

One young man in Balata Camp expressed a frustration that reflects the common experience. He is the fifth of five sons who live with their parents in a small house in the camp. All four of his brothers are married with three to five children each. The young man said he feels very happy when he is outside the camp but when he enters the camp there is a black cloud over his head. He feels there is no room in the house for him; he sleeps in the corridor and must endure 'bedroom' noises. He feels he has no privacy; along with his neighbours, everything he does in the bathroom is heard by his own as well as neighbouring households. He cannot enter his home without first knocking and waiting several minutes outside in order to give his sisters-in-law time to cover their hair with their scarves.

3.12 Differential impact on various segments of the population

3.12.1 Women

Palestinian refugee women lost the productive role they once had in their village community working with their fathers, brothers and husbands in the fields. In the refugee camps their role is confined within the boundaries of their shelter, which affects their position and influence in society. Women and children suffer most from the lack of infrastructure and services such as sanitation, refuse disposal, water supply, roads and paths and electrification. And lack of communal spaces for social activities, affects women for particular reasons (Budeiri 1996:75).

That is, women are more likely to remain within the confines of the home and camp for cultural and economic reasons which are both reinforced by the effects of overcrowding. Women have greater responsibilities at home from running an over-burdened household, and limited economic opportunities. In Gaza, 19 percent of the 139,910 refugee households are headed by women (Budeiri 1996:72). Overcrowding makes it more difficult for women to manage the home and carry out their multiple roles and responsibilities. It is more difficult to keep the home clean.

Overcrowding in the home also jeopardizes women's privacy: the numbers of people in the home means that space is not available away from others. Similarly, the greater number of children and adults in the confined space of the home means that continual demands and interruptions are the norm. These effects of overcrowding, as indicated in the literature reviewed in Section 2, have serious bearing on psychological well-being for women in the home.

Further, the home itself becomes more enclosed because of the encroachment onto the space immediately outside the walls of the home by other houses. Aside from the basic (overburdened) services provided by UNRWA facillities in each camp, there are Women's Activities Centres in all but five camps in the West Bank. The facilities of the Centres are reportedly 'reasonable' but not sufficient to address women's needs in terms of the amount of space they provide. Despite the constricted environment of the overcrowded camps, the central location of social services such as education, health and relief within the established boundaries of the camps provide easy accessibility for women as they are always within their neighbourhoods (Budeiri 1996:75).

3.12.2 Children and youth

Schooling: Poor school facilities and conditions impact on the society as a whole. Nonethleless, children and youth suffer from overcrowding in the home and school in very direct ways. UNRWA schools in several camps often have 50-60 children in a classroom . Typically, there are two shifts each day, with half the students attending in the morning and the other half in the afternoon. Teacher trainers working in Jenin camp report that the schools are old and the methods are not suitable. There is a lack of facilities which makes both learning and teaching difficult. Many kids of 14 years of age cannot read letters of the alphabet, although they are in school.

The crowded homes make it difficult for children to concentrate on their studies. An UNRWA field officer noted:

I received a letter from a student, a 13-year old girl living with 10 brothers and sisters. She wrote that her house was too crowded and was affecting her learning. She is not reading well and asked if her family could get permission to expand their home.

Additionally, pressures at home from the demands of a crowded household mean that girls are sometimes pulled out of school to help their mothers in the home.

Early marriage: In the last decade, there has been a concern that the early marriages of girls had begun to increase. Overcrowded homes, which constrict girls' opportunities and overburden parents, serves to encourage the incidence of early marriage. Girls are not seen as potential income-earners and their education is not considered useful to the family; hence, they are encouraged to try to improve their prospects by marrying as early as age 14 or 15. This has profound repercussions for the girls, as well as generational impacts for camp residents and Palestinian society as a whole. For example, maternal literacy is known to be closely associated with infant mortality rate and nutritional status (Cook 1992:284).

Boys have more freedom of movement and, hence, are less restricted within the confines of the home. But, boys' schooling is also jeopardized, with boys representing 40% of school dropouts. Reportedly, they "have an unwillingness to study," according to an UNRWA representative. Upon leaving school, boys often try to work in Israel in construction and farming wherein they are paid less than men and do not have any labour rights protection.

3.12.3 Men

Overcrowding, along with the poor economic situation, places greater pressures on men. Gazans report that the situation has worsened since the end of the intifada. Men are leaving home to escape problems; domestic violence is greater, especially among the men who are returned from prison. In terms of basic needs, every family reportedly requires help (Doughty 1996:73). The social fabric is generally strained as a result.

3.12.4 Elderly

With the narrow lane-ways and streets, there is little ventilation for first floors of dwellings, and the sun cannot enter to dry the humidity. Many older people have asthma, which is seen as resulting from the poor air ventilation of homes. Issues of privacy, health, social relations need to be looked at more closely with regard to the elderly in overcrowded homes and refugee camps.

3.12.5 Disabled

The conditions of overcrowding have particular ramifications for disabled residents of the camps. Disabled people are not able to move around in or outside their homes. Overcrowding in the home means that the mother is not able to properly attend to the needs of the disabled child or children. Schools do not have enough resources for the blind or deaf. Space in homes are too constrained to build large enough bathrooms to accommodate disabled members of the family.

In the West Bank, all except six camps have centres for disabled residents of the camp. The centres provide mainly referral services to other institutes for specialized treatment. They also run special education classes, visit disabled residents in their homes, provide assistance to mothers in their care and treatment, provide therapy and prosthetic devices, and help in modifying the home. There are not enough physiotherapists to address the needs of disabled residents.

The following summarizes the main findings and presents recommendations regarding future study of the issue of overcrowding.

Nature of the problem:

Overcrowding and its associative effects derive from:

the high 'social density' in homes, schools, clinics, camps;

the high 'spatial density' of the camp, in particular, congested buildings and roads, and lack of public spaces, including playgrounds and meeting places.

the burden placed on the already insufficient infrastructure and utilities, including roads, water supply, and electricity, and public services, including health and education.

The social and psychological effects of overcrowding are immediate, long-term, cumulative, multiple, mutually reinforcing, direct as well as indirect, and critical. Overcrowding is likely to worsen.

Where problems of overcrowding manifest:

Overcrowding affects all segments of the refugee camps' population in common and particular ways. Social and psychological effects of overcrowding are experienced among individuals and within relationships

within households,

between families and households,

within the camp as a whole, as a result of crowded and overburdened social services and increased physical congestion, and

between camp residents and the wider society in the West Bank and Gaza.

The social and psychological effects:

The social and psychological effects of overcrowding can be summarized as follows:

Health effects:

Overcrowding poses serious direct and indirect health risks to all segments of the population, particularly the elderly and young children.

Social effects:

Overcrowding contributes to far-reaching social problems. For example, overcrowding:

in schools and homes contributes to substandard education and functional illiteracy, and may be related to increased child labour.

is a 'push factor' in the decisions leading to girls' early marriage (before the age of 18) which, in turn, leads to serious health and social ramifications for women.

places a strain on social relations within the home and community.

affects women's access to social and economic resources as it increases their responsibilities in the home.

potentially places disabled residents of camps in jeopardy in terms of their physical and social development.

Psychological effects:

The psychological effects of overcrowding are interlinked with social effects. Overcrowding contributes to psychological frustrations which, in turn, have a bearing on behavioural responses and one's ability to cope with the conditions. Overcrowding also has a bearing on refugees' perception of options and future prospects.

In combination with other conditions:

Overcrowding exacerbates other problems in the refugee camps, and results in potentially fatal consequences and health risks due to, for example, insufficient and poor water supply and poor sanitation systems.

Programmes addressing overcrowding:

There are insufficient programmes on the part of NGOs, and insufficient resources allocated, to address social and psychological effects of overcrowding. Nonetheless, there is a great deal of concern about the issue and a belief that it is of critical importance.

Recommendations for further study:

There is not enough information or analysis on the direct and indirect effects of overcrowding. There is a need for further study to unravel the inter-relationships of numerous effects and conditions associated with overcrowding.

Further study should:

involve direct 'on the ground' information gathering from those working and living in refugee camps.

include both qualitative and quantitative data gathering.

aim to the develop programmes or projects that can address short-, medium- and long-term needs and issues. For example, in the short term, the direct conditions of overcrowding can be alleviated through encouraging more stringent adherence to building codes, and use of improved building materials in construction of additions to homes, and insufficient social services.

incorporate the concerns and needs of camp residents and be alert to institutes interested in coordinating study in this area.

Finally, despite lack of agreement on the part of stakeholders concerning substantive issues linked to any solution to overcrowding, there is an urgency around the issue as well as sufficient scope to address the issues above.

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